Informed Consent and Digit Replantation: Current State and Recommendations for Ethical Patient Care.

The importance of informed consent and the value of shared decision-making in hand surgery are well-established and particularly critical in the setting of digit amputation when considering replantation. Informed consent requires an understanding of not only the immediate and long-term risks and benefits of surgery, as well as the risks and alternatives involved, but also the capacity of the patient to make a medical decision. However, patients who have acutely sustained a disfiguring trauma are often in distress and may not fully process the consent discussion. Digit replantation is an "elective emergency"-the decision must be made immediately but is not lifesaving-which poses a difficult dilemma: are surgeons acting in patients' best interests by pursuing replantation if we engage those patients in informed consent discussions when they may not have capacity? This article explores the relevant bioethical principles associated with digit replantation, summarizes updated literature regarding informed consent and shared decision-making, and provides recommendations for patient education materials to standardize informed consent discussions for surgeons approaching patients at this unique intersection of considering revision amputation versus replantation.

Wide Awake Trigger Finger Releases Performed in the United States: Trends in Volume, Operative Setting, and Reimbursement.

BACKGROUND: Trigger finger release (TFR) has traditionally been performed in outpatient operating rooms. More recently, TFR may be performed in the office setting to achieve greater efficiency and cost savings. METHODS: The 2010-2020 Q2 PearlDiver M91Ortho data set was analyzed for cases of TFR. Exclusion criteria were age less than 18 years, <30 days of postoperative records, concomitant hand surgery, monitored anesthesia use, and inpatient surgery. Age, sex, and Elixhauser comorbidity index were recorded. Operating room and office procedures were matched 4:1 based on patient characteristics. Total and physician reimbursement for the day of surgery, as well as 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSI) were determined. RESULTS: Before matching, TFRs were found to be increasingly performed in the office (from 7.9% in 2010 to 14.6% in 2020). Matched cohorts consisted of 63,951 operating room and 15,992 office procedures. Office procedures had lower mean total reimbursements ($435 vs $752, P < 0.001), slightly lower mean physician reimbursements ($420 vs $460, P < 0.001), and lower rates of narcotic prescriptions (30.5% vs 50.5%, P < 0.001) and 30-day ED visits (2.2% vs 2.9%, P < 0.05). There was no difference in 30-day SSI (0.5% vs 0.6%, P = 0.374). CONCLUSIONS: In-office TFR is becoming increasingly prevalent. After matching, in-office TFRs were associated with lesser costs to the system, lower narcotic prescriptions, and fewer postoperative ED visits, without increased SSI. Although it is important to perform procedures in the best location for the patient, physician, and system, the current study supports the increased value offered by in-office TFR.

The Role of Cadaver-Based Flap Course in Microsurgical Education and Practice Patterns of Attendees: A Survey Study.

BACKGROUND: In 2017, our institution initiated a cadaver laboratory-based course dedicated to teaching reconstructive microsurgery indications, preoperative planning, and flap dissection. The goals of this study are to describe the demographics and experience of participants/instructors and to evaluate the learning objectives and effectiveness of the course. METHODS: Penn Flap Course (PFC) participants were sent an anonymous survey at the inaugural PFC 2017. Then, in 2019, both instructors and participants were sent a more comprehensive survey. Surveys included questions regarding demographics, training background, experiences in practice and/or training, and course evaluation. RESULTS: At PFC 2017, participant response rate was 25% (12/44), and the primary reason for attending the course was to observe and learn from instructor dissections (66.7%). At PFC 2019, the response rate was 77.3% (17/22) for faculty and 73.0% (35/48) for participants. Both in 2017 and 2019, the vast majority of participants reported perceived improvement in understanding of flap dissection principles across all anatomic domains (94.3%-100%). In 2019, when asked about their background experience, the majority of participants reported comfort performing arterial and venous anastomosis without supervision (71%-77%) and being least comfortable with head and neck (H&N) microsurgery (mean comfort level: 5.2/10). Half of the participants (e.g., residents) find the presence of a microsurgery fellow at their institution useful to their educational experience. Instructors with additional fellowship training in microsurgery reported performing a higher volume of free flaps per week (7 vs. 2.3) and per year (94.2 vs. 27.8; p < 0.05 for both) and trend toward performing more H&N reconstruction (p = 0.057). CONCLUSION: Participants feel least comfortable with H&N microsurgical reconstruction. Surgical faculty with microsurgical fellowship training performs greater volume of microsurgical cases with a trend toward more H&N reconstruction. A cadaver/lecture-based flap course is an effective way to improve participants' perceived confidence and understanding of complex flap and microsurgical reconstructive procedures.

Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience.

BACKGROUND: Mesh infection after abdominal hernia repair is a devastating complication that affects general and plastic surgeons alike. The purpose of this study was 3-fold: (1) to determine current evidence for treatment of infected abdominal wall mesh via systematic review of literature, (2) to analyze our single-institution experience with treatment of infected mesh patients, and (3) to establish a framework for how to approach this complex clinical problem. METHODS: Literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, followed by single-institution retrospective analysis of infected mesh patients. RESULTS: A total of 3565 abstracts and 92 full-text articles were reviewed. For qualitative and quantitative assessment, articles were subdivided on the basis of treatment approach: "conservative management," "excision of mesh with primary closure," "single-stage reconstruction," "immediate staged repair," and "repair in contaminated field." Evidence for each treatment approach is presented. At our institution, most patients (40/43) were treated by excision of infected mesh and single-stage reconstruction with biologic mesh. When the mesh was placed in a retrorectus or underlay fashion, 21.4% rate of hernia recurrence was achieved. Bridged repairs were highly prone to recurrence (88.9%; P = 0.001), but the bridging biologic mesh seemed to maintain domain and potentially contribute to a more effective repair in the future. Of the patients who underwent additional ("secondary") repairs after recurrence, 75% were eventually able to achieve "hernia-free" state. CONCLUSIONS: This study reviews the literature and our single-institution experience regarding treatment of infected abdominal wall mesh. Framework is developed for how to approach this complex clinical problem.

Godina's Principles in the Twenty-First Century and the Evolution of Lower Extremity Trauma Reconstruction.

BACKGROUND: February of 2016 marked 30 years since the passing of Marko Godina, a pioneer and prodigy in the field of reconstructive microsurgery. Most noteworthy among his many contributions was his method of radical debridement of contaminated compound fractures followed by early free tissue transfer for wound closure. In the last three decades, the landscape of reconstructive surgery has undergone significant transformation owing to advances in reconstructive techniques and wound care technology, as well as new data. METHODS: Dr. Godina's work and legacy are reviewed, compared and contrasted with new and evolving data regarding lower extremity trauma reconstruction. RESULTS: Advancements in technique and technology have greatly molded lower extremtiy reconstruction over the past thirty years. Nonetheless, Dr. Godina's principles of timely care and early vascularized soft tissue coverage have withstood the test of time. CONCLUSION: Marko Godina's contribution to reconstructive microsurgery cannot be overstated and his groundbreaking work continues to serve as the foundation of lower extremity trauma reconstruction. Three decades after his seminal work, we honor Dr. Godina's legacy and explore how his principles have endured, evolved, or been replaced.

Radial Longitudinal Deficiency: Recent Developments, Controversies, and an Evidence-Based Guide to Treatment.

Radial longitudinal deficiency (RLD) is the most common congenital longitudinal deficiency at birth and represents a wide spectrum of upper extremity anomalies, from mild thumb hypoplasia to absent radius. Radial dysplasia may be isolated or associated with an array of systemic anomalies that should be familiar to pediatric hand surgeons. The management of RLD has evolved greatly since its inception in the late 19th century, largely due to decades of innovation that followed the thalidomide catastrophe of the 1960s. Yet controversy still exists regarding many aspects of RLD. Traditional treatments of radial dysplasia (ie, centralization) are unfortunately wrought with poor outcomes and high rates of recurrence, leading some authors to recommend alternative techniques for this condition. Reconstruction of the hypoplastic thumb, although less controversial, is just starting to see long-term outcomes. This article reviews the etiology, classification, and treatment options for RLD, highlighting recent developments and outcomes.

The Correlation of Surgical Setting With Perioperative Opioid Prescriptions for Wide-Awake Carpal Tunnel Release.

BACKGROUND: Prior studies have compared perioperative opioid prescriptions between carpal tunnel release (CTR) performed wide-awake and with traditional anesthetic techniques, but the association of opioid prescriptions with surgical setting has not been fully explored. The current study assessed the association of opioid prescriptions with surgical setting (office or operating room) for wide-awake CTR. METHODS: Patients with open CTR were identified in an administrative claims database (PearlDiver). Exclusion criteria included age less than 18 years, preoperative data less than 6 months, postoperative data less than 1 month, bilateral surgery, concomitant hand surgery, and traditional anesthesia (general anesthesia, sedation, or regional block). Patients were stratified by surgical setting (office or operating room) and matched by age, sex, Elixhauser Comorbidity Index, and geographic region. Prior opioid prescriptions, opioid dependence/abuse, substance use disorder, back/neck pain, generalized anxiety, and major depression were identified. Opioid prescriptions within 7 days before and 30 days after surgery were characterized. RESULTS: Each matched cohort included 5713 patients. Compared with patients with surgery in the operating room, fewer patients with office-based surgery filled opioid prescriptions (45% vs 62%), and those prescriptions had lower morphine milligram equivalents (MMEs, median 130 vs 188). These findings were statistically significant on univariate and multivariate analysis. CONCLUSIONS: Following office-based CTR, fewer patients filled opioid prescriptions, and filled prescriptions had lower MME. This likely reflects patient and provider attitudes about pain control and opioid utilization. Further patient- and provider-level investigation may provide additional insights that could aid in efforts to reduce perioperative opioid utilization across surgical settings.

Wide-Awake Carpal Tunnel Release in the United States: Trends in Volume and Reimbursement by Operative Setting.

BACKGROUND: Office-based surgery can increase logistical and financial efficiency for patients and surgeons. The current study compares wide-awake office-based carpal tunnel release to wide-awake surgeries performed in the operating room (OR) in terms of volume, financial burden, narcotic prescriptions, and adverse events. METHODS: Surgeries performed under local-only anesthesia from 2010 to 2020 were identified in a national administrative database (PearlDiver™). Patients were grouped by surgical setting and matched based on age, sex, comorbidity burden, and geographic region. Primary endpoints included total disbursement and physician reimbursement, as well as 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSI). RESULTS: Before matching, there were 303,741 OR surgeries and 5,463 office surgeries. From 2010 to 2020, the percent of surgeries in the office increased from 1.2% to 3.4%. Matched cohorts included 21,835 OR surgeries and 5,459 office surgeries. Office surgery was associated with lower total disbursement and physician reimbursement for patients with commercial insurance, Medicaid, and Medicare. Linear regression modeling indicated that office-based surgery was significantly associated with lower total disbursement and physician reimbursement. Fewer office patients filled narcotic prescriptions and visited the ED, and there was no difference in SSI. CONCLUSION: Compared to OR surgery, office surgery was associated with lower financial burden, fewer narcotics prescriptions and ED visits, and similar incidence of SSI. These findings, together with literature showing greater efficiency in the office, suggest that office-based surgeries are safe and cost-effective and should continue to grow.

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood. METHODS: A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage. RESULTS: In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027). CONCLUSION: The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA. LEVEL OF EVIDENCE: Level IV.

Pediatric Hand and Upper Extremity Injuries Presenting to Emergency Departments in the United States: Epidemiology and Health Care-Associated Costs.

Background: Upper extremity injuries represent one of the most common pediatric conditions presenting to emergency departments (EDs) in the United States. We aim to describe the epidemiology, trends, and costs of pediatric patients who present to US EDs with upper extremity injuries. Methods: Using the National Emergency Department Sample, we identified all ED encounters by patients aged <18 years associated with a primary diagnosis involving the upper extremity from 2008 to 2012. Patients were divided into 4 groups by age (≤5 years, 6-9 years, 10-13 years, and 14-17 years) and a trauma subgroup. Primary outcomes were prevalence, etiology, and associated charges. Results: In total, 11.7 million ED encounters were identified, and 89.8% had a primary diagnosis involving the upper extremity. Fracture was the most common injury type (28.2%). Dislocations were common in the youngest group (17.7%) but rare in the other 3 (range = 0.8%-1.6%). There were 73.2% of trauma-related visits, most commonly due to falls (29.9%); 96.9% of trauma patients were discharged home from the ED. There were bimodal peaks of incidence in the spring and fall and a nadir in the winter. Emergency department charges of $21.2 billion were generated during the 4 years studied. While volume of visits decreased during the study, associated charges rose by 1.21%. Conclusions: Pediatric upper extremity injuries place burden on the economy of the US health care system. Types of injuries and anticipated payers vary among age groups, and while total yearly visits have decreased over the study period, the average cost of visits has risen.

The Medial Femoral Condyle Flap in the Pediatric Patient.

BACKGROUND: The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population. METHODS: A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate. RESULTS: Thirteen patients met inclusion criteria, with an average age of 14.7 years (range, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies. CONCLUSIONS: The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Toxic Shock Syndrome after Surgery: Case Presentation and Systematic Review of the Literature.

Toxic shock syndrome (TSS) is an underrecognized but highly fatal cause of septic shock in postoperative patients. Although it may present with no overt source of infection, its course is devastating and rapidly progressive. Surgeon awareness is needed to recognize and treat this condition appropriately. In this paper, we aim to describe a case of postoperative TSS, present a systematic review of the literature, and provide an overview of the disease for the surgeon. METHODS: A systematic review of the literature between 1978 and 2018 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the keywords "toxic shock syndrome" and "surgery." Variables of interest were collected in each report. RESULTS: A total of 298 reports were screened, and 67 reports describing 96 individual patients met inclusion criteria. Six reports described a streptococcal cause, although the vast majority attributed TSS to Staphylococcus aureus (SA). The mortality in our review was 9.4%, although 24% of patients suffered some manner of permanent complication. TSS presented at a median of 4 days postoperatively, with most cases occurring within 10 days. CONCLUSIONS: Surgeons must maintain a high index of suspicion for postoperative TSS. Our review demonstrates that TSS should not be excluded despite young patient age, patient health, or relative simplicity of a procedure. Symptoms such as fever, rash, pain out of proportion to examination, and diarrhea or emesis should raise concern for TSS and prompt exploration and cultures even of benign-appearing postoperative wounds.

Microvascular free flap coverage for salvage of the infected total knee arthroplasty.

AIMS: The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA. METHODS: We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. RESULTS: In all, one patient was lost to follow-up prior to 12 months. The remaining 22 patients were followed for a mean of 46 months (12 to 92). At latest follow-up, four patients (18%) had undergone amputation for failure of treatment and persistent infection. For the other 18 patients, 11 patients (50%) had maintained a knee prosthesis in place while seven patients had undergone resections for persistent infection but retained their limbs (32%). Reoperations were common following coverage and reimplantation. The median number of additional procedures was two (0 to 6). Clinical function was poor in patients who underwent reimplantation and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (0 to 70) and 30 (0 to 65), respectively. All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. CONCLUSION: Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (82%) but clinical outcomes in salvaged limbs were poor. Cite this article: Bone Joint J 2020;102-B(6 Supple A):176-180.

The Independent Plastic Surgery Match (2010-2018): Applicant and Program Trends, Predictors of a Successful Match, and Future Directions.

OBJECTIVES: Changes were made to the independent plastic surgery residency in 2009 to 2010 that included full prerequisite training and increased from 2 to 3 years of independent residency. The authors sought to determine subsequent match trends and predictors of a successful match. METHODS: With American Council of Academic Plastic Surgeons approval, the San Francisco Match provided data for the independent match (2010-2018). Trends in the independent plastic surgery were reviewed. Applicant variables were analyzed to determine correlation with a successful match and a match at top-ranked programs using Doximity Residency Navigator. RESULTS: Total independent applicants per cycle decreased 18% while foreign medical school applicants increased from 19.4% to 27%. Available positions decreased from 97 to 66 (32%) and match rate decreased from 82% to 78%. Applicants who matched were from US medical schools, had higher USMLE Step 1 scores, were from University and top General surgery residencies, and averaged more interviews (p < 0.05). By multivariate regression, number of interviews completed (odds ratio [OR] 15.35 95% confidence interval [CI] 7.7-30.6, p < 0.001) and having completed prerequisite training at a university based program in addition to having graduated from an allopathic medical school (OR 1.78 95% CI 1.1-2.97, p = 0.027) were predictive of a successful match. Step 1 score ≥ 240 (OR 3.2, 95% CI 1.0-10.2, p = 0.046), Alpha Omega Alpha membership (OR 2.2, 95% CI 1.1-4.9, p = 0.048), and having completed prerequisite training at the same institution (7.6, 95% CI 2.2-25.7, p < 0.001) were predictive of matching at top-ranked programs. CONCLUSIONS: Since 2010, independent plastic surgery applicant and program participation have decreased. Greater number of interviews, university-based prerequisite training, and allopathic medical school background are variables that correlate with a successful match. Factors predictive of a match at top-ranked Doximity Residency Navigator plastic surgery programs include high Step 1 scores, Alpha Omega Alpha membership, and prerequisite training at the same institution.

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series.

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique. Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations. Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation. Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Burden of Hand Maladies in US Emergency Departments.

BACKGROUND: Hand conditions commonly present to the emergency department (ED), yet data are lacking regarding the magnitude of hand-related conditions in the emergency setting. The purpose of this study is to describe the burden and quantify the health care resource utilization of hand conditions seen in EDs across the United States. METHODS: Using the National Emergency Department Sample, we identified all ED encounters by patients at least 18 years of age that were associated with a hand condition in 2009 to 2012. The primary outcomes were prevalence, etiology, and associated health care charges for specific categories of hand conditions. RESULTS: The final sample included 34.4 million ED encounters associated with a common hand condition generating $180.4 billion in health care charges. The volume of hand-related presentations varied in a predictable and cyclical manner, peaking in July and waning in December of each year. Trauma was the most common etiology (77.5%) predominantly due to falls (26.2%) and lacerations (19.7%). Over 4 years, the volume of ED encounters rose (5% increase, P < .001) and as did the resulting health care charges (24.6% increase, P < .001). CONCLUSIONS: Our study confirms that hand-related conditions contribute significantly to ED volume and consume a growing quantity of health care resources in the United States. The volume of patients presenting to EDs with hand-related conditions fluctuates cyclically throughout the year. Open wounds are the most common cause of presentation and mostly occur in young adults, followed by joint pain, contusions, and fractures.

Soft-Tissue Reconstruction of the Complicated Knee Arthroplasty: Principles and Predictors of Salvage.

BACKGROUND: Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes. METHODS: A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher's exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation. RESULTS: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation. CONCLUSIONS: In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Anatomical Basis and Clinical Application of Synovial Flaps in the Wrist and Distal Forearm.

BACKGROUND: Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed. METHODS: Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region. RESULTS: All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms. CONCLUSIONS: When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.

Colovesical fistula caused by an ingested chicken bone.

Colovesical fistula involving the sigmoid colon is the most common fistulous communication between the gastrointestinal tract and the urinary bladder. These tracts are most commonly associated with diverticulitis but might arise secondary to a neoplasm, inflammatory bowel disease, iatrogenic injuries, radiation therapy, trauma, or foreign bodies. We describe a patient who developed a fistula between the sigmoid colon and bladder secondary to an ingested chicken bone that lodged in a colonic diverticulum. A portion of the foreign body was removed by direct visualization on colonoscopy; the remaining fragment passed spontaneously per urethra after hospital discharge.

Reduction mammoplasty operative techniques for improved outcomes in the treatment of gigantomastia.

OBJECTIVE: Gigantomastia, or excessive breast hypertrophy, which is broadly defined as macromastia requiring a surgical reduction of more than 1500 g of breast tissue per breast, poses a unique problem to the reconstructive surgeon. Various procedures have been described for reduction mammoplasty with specific skin incisions, patterns of breast parenchymal resection, and blood supply to the nipple-areolar complex; however, not all of these techniques can be directly applied in the setting of gigantomastia. We outline a simplified method for preoperative evaluation and operative technique, which has been optimized for the management of gigantomastia. METHODS: A retrospective chart review of patients who have undergone reduction mammoplasty from 2006 to 2011 by a single surgeon at the University of Virginia was performed. Patients were subdivided based on weight of breast tissue resection into 2 groups: macromastia (<1500 g resection per breast) and gigantomastia (>1500 g resection per breast). Endpoints including patient demographics, operative techniques, and complication rates were recorded. RESULTS: The mean resection weights in the macromastia and gigantomastia groups, respectively, were 681 g ± 283 g and 2554 g ± 421 g. There were no differences in major complications between the 2 groups. The rate of free nipple graft utilization was not significantly different between the 2 groups. CONCLUSIONS: Our surgical approach to gigantomastia has advantages when applied to extremely large-volume breast reduction and provides both esthetic and reproducible results. The preoperative assessment and operative techniques described herein have been adapted to the management of gigantomastia to reduce the rates of surgical complications.